Deceased
John Francis Flynn
Demographics
69y, male
Coroner
Coroner Katherine Lorenz
Date of death
2019-12-24
Finding date
2021-10-26
Cause of death
Hypoxic ischaemic brain injury secondary to right facial artery pseudoaneurysm rupture and haemorrhage
AI-generated summary
69-year-old male with tonsillar squamous cell carcinoma presenting with throat pain and trismus 12 days after completing chemoradiotherapy. On presentation to emergency department with bleeding, airway risk was under-recognised despite clinical assessment noting significant risk if bleeding recurred. Missed opportunities included delayed senior ENT consultation, failure to secure airway electively before catastrophic bleed, and suboptimal escalation. Massive haemorrhage occurred, requiring emergency cricothyrotomy and resuscitation. Subsequent hypoxic-ischaemic brain injury proved fatal. Hospital review identified under-recognition of airway threat and communication delays. New protocol now mandates pre-emptive tracheostomy for post-chemoradiotherapy oropharyngeal bleeds. Key lessons: recognise sentinel airway risk, escalate senior expertise early, secure airway before life-threatening haemorrhage.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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Elizabeth Ferris, a 44-year-old woman with schizoaffective disorder and polysubstance use disorder, died from hypoxic ischaemic encephalopathy following cardiac arrest in the setting of presumed drug toxicity. She was fo…
87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…
An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…
53y · Male·Aspiration pneumonia in the setting of Down syndrome and pelvic fractures
Damien Mark Stone, a 53-year-old man with Down syndrome and early-onset Alzheimer's disease, died from aspiration pneumonia following a pelvic fracture sustained during hospital admission. Key clinical lessons include: (…
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